IPGA MEMBERSHIP APPLICATION

International Policy Governance® Association

MEMBERSHIP APPLICATION

Please note: For application purposes, the following form and appended notes may be printed directly from your browser menu options.

1.  Name: __________________________________________________________________

2.  Organization: __________________________________________________________

3.  Mailing Address: _______________________________________________________

                     _______________________________________________________

                     _______________________________________________________

4.  Daytime Phone:         | 5.  Cell:              | 6.  Fax:
                           |                        |
    ______________________ | ______________________ | ______________________

7.  Email: _________________________________________________________________
(Association newsletters are distributed electronically unless otherwise requested.)

8.  Type of Membership Applied For:  please check the relevant category

    Full ___                Supporting ___                Organizational ___

PLEASE READ THE ENDNOTES BEFORE COMPLETING THIS APPLICATION

For Full Member Applicants Only (See endnotes)

  9.   When did you complete the Policy Governance Academy^SM? (month/year) ________________
10.   Please give evidence of your commitment to continuing professional development in relation to Policy Governance®. Continue on separate sheet if necessary.

11.   How many years have you been engaged in Policy Governance consulting or implementation? __________
12.   On average, for what proportion of your working week are you engaged in Policy Governance® consulting or implementing? __________%
13.   Please give a brief overview of the nature of this work. Continue on separate sheet if necessary.

For Supporting Member Applicants Only (See endnotes)

14.   Please describe your involvement with Policy Governance? Continue on separate sheet if necessary

15.   Please describe any Policy Governance training you have had to date. Continue on separate sheet if necessary

16.   Please describe your interest in becoming a Supporting Member of IPGA. Continue on separate sheet if necessary.

For Organizational Members Only (See endnotes)

17. Please describe your organization's commitment to the use of the Policy Governance model. Continue on separate sheet if necessary.

18. Please give evidence of your organization's commitment to upholding the value of quality Policy Governance implementation, education and training. Continue on separate sheet if necessary.

FOR ALL APPLICANTS (See endnotes)

19. Please give any further evidence of your commitment to the Association's Ends.

20. Membership Fee enclosed: please circle appropriate amount

$200                     $100                     $300
Full Member              Supporting Member        Organizational Member

Please make cheques payable in US dollars to 'International Policy Governance Association'.

21. Receipt Required: Yes / No

22. I have read the conditions of membership and agree to be bound by them. Please check ___

Signature: _____________________________  Date: __________________(dd/mm/yy)

Please mail your application with fee to:
Susan Mogensen, CEO
International Policy Governance® Association,
1010 Bosque Crescent,
Cumberland, Ontario, K4C 1C3 Canada.

Telephone: 613-833-2766, Fax: (613) 833-2716
Email: info@policygovernanceassociation.org

NOTES TO INTERNATIONAL POLICY GOVERNANCE® ASSOCIATION APPLICATION FORM

Question 8:
Full Members must have completed the Policy Governance Academy^SM and have significant experience in consulting or implementation over at least two years. They must also be able to demonstrate commitment to continuing professional development and the Association's Ends. The one-year membership fee is US$200. Full members are the only members entitled to vote at the Annual General Meeting.
Supporting Members are individuals interested in supporting IPGA and its purpose. Although no prior training or experience is required, members are requested to provide information regarding their Policy Governance background and interest in supporting IPGA. The one-year membership fee is US$100.
Organizational Members must be able to demonstrate commitment to: a) the use of the Policy Governance model, b) upholding the value of quality Policy Governance implementation and c) the Association's Ends. The one-year membership fee for organizations is US$300.

Question 9:
Carver Governance Design Inc conducts Policy Governance Academies on a regular basis. For further information call: 404-728-9444 or visit www.carvergovernance.com The Academy is currently the only training that meets the Association's standards for Full Membership. The Association's board will consider other advanced trainings as and when they are developed.

Question 10:
Evidence might include: books you have studied, subscriptions to relevant journals, attendance at Policy Governance® symposia, participation in other Policy Governance trainings and workshops. Please be sure to include the duration of the training and who ran the training.

Question 14:
You may be or have been a consultant or trainer, a board member or CEO of a board using Policy Governance or you may not have had any involvement in Policy Governance. In this latter case, please describe your interest in Policy Governance.

Question 15:
Please be sure to include the duration of the training and who ran the training.

Question 16:
Please freely express why you want to be a Supporting Member of IPGA .

Question 17:
You can include information such as: when your organization adopted Policy Governance, how it trained itself before adopting Policy Governance and what changes it effected.

Question 18:
See Question 10 above plus information such as how the board monitors its adherence to its policies.

Question 19:
Examples of further evidence of your commitment to the Association's Ends might include: efforts to spread awareness of the value of Policy Governance implementation or to ensure that the board or boards that you work with are equipped to operate Policy Governance with integrity.

Question 20:
Accepted methods of payment are credit card (Visa, MasterCard, and American Express), check or money order in $U.S. to the International Policy Governance Association, or wire transfer. To request wire transfer instructions, please send an e-mail to info@policygovernanceassociation.org. We cannot accept debit card payments or cash.

Question 21:
Receipts will give your name, the name of your organization and be sent to the mailing address supplied unless otherwise requested.

Question 22:
Conditions of Membership: The determination of membership eligibility according to the above criteria is at the sole discretion of the Board of Directors. Annual membership is effective upon payment of membership fees determined by the Board of Directors each year. Failure to maintain compliance with eligibility requirements may result in revocation of membership by the Board of Directors, subject to a reasonable appeals process.

Policy Governance is a service mark of John Carver. Used with Permission.